Clinical Practice Guidelines

Sanford Health Plan is responsible for adopting and distributing clinical practice guidelines for acute, chronic and behavioral health care services that are relevant to our membership. Clinical practice guidelines are systematically developed statements that help practitioners and members make decisions about appropriate health care for specific clinical circumstances. These guidelines can improve health care and reduce unnecessary variations in practice patterns. Practice guidelines are based on reasonable medical evidence, such as clinical literature and expert consensus. The Plan's multi-specialty physician committee, the Physician Quality Committee, has reviewed and approved practice guidelines for numerous conditions. Where links are provided, Sanford Health Plan has adopted the clinical practice guidelines exactly as they are written by the respective organizations. If you have any questions or suggestions regarding these guidelines or would like to request a copy of the guidelines, please visit the mySanfordHealthPlan provider portal or call the Health Plan at (800) 601-5086 or (605) 328-6877.

Clinical Practice Guidelines Adopted from Sanford Health

The following guidelines in this section were developed by the Sanford Clinical Practice Committee and adopted by Sanford Health Plan's Physician Quality Committee.

Preventive Guidelines

Pharmacy Information

The Sanford Health Plan Formulary is a list of medications that are the most effective for the treatment and diagnosis of disease and maintenance of health according to the clinical judgment of the physicians, pharmacists and other health care professionals who serve on the Physicians Quality Committee that approved the formulary.

For a complete listing of the formulary and pharmacy management procedures (including things like generic substitution, prior authorization, step therapy protocols and more). Log on to your provider account here.

Summary of Pharmacy Benefits Booklet

Formulary (list of approved drugs)

What If a Prescription Drug Is Not On The Formulary?
Sanford Health Plan uses a Formulary to help members save money and help control the costs of healthcare. Of course, not all drugs are included in the formulary. However, we understand that sometimes exceptions must be made. A Medication Request Form can be used if:

You feel it's medically necessary to allow the member to take a drug that is not listed on our formulary; or

The member has tried our Step Therapy program and cannot tolerate the side effects or the use of the Step Therapy drugs are contraindicated and you would like authorization for coverage of those drugs.

If you have questions regarding our formulary, contact our Pharmacy Management Team at the numbers below: